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The RCA team in the examined case includes three people: the risk manager, the RN who works in the involved unit full-time, and the technician who works at the pharmacy. The fulltime employees can provide vital information about their respective workplace settings. The RN, for instance, knows about issues that all nurses encounter during their shifts. Moreover, she knows how each medication was used in the situation, what steps nurses have to take to administer drugs, and what knowledge nurses have to possess (Spath, 2013).
Similarly, the pharmacy technician can describe the state of the pharmacy’s workers, their knowledge, skills, and equipment. Finally, the risk manager organizes the other members and assists in developing charts, interviewing employees, and analyzing the gathered information. The conversation among the team members during the first meeting led to collaborative efforts for problem-solving. The risk manager pointed out that the primary purpose of the RCA was to provide better care to patients. The RN and technician apologized for their comments, acknowledged each others’ contribution to healthcare, and disclosed the issues that each organization had.
However, the team’s collaboration did not start immediately, as the RN and the pharmacy director began the discussion with trying to blame each other. This process was not contributing to the success of the team since arguing did not lead to mutual communication and understanding (Yoder-Wise, 2015). By discussing each other’s flaws, the members did not search for root causes. After resolving their concerns and focusing on the task and goals, the team members were able to produce three charts which could assist them in developing a quality improvement initiative.
One of them was a Pareto Chart which analyzed various problems in the hospital and the pharmacy and established which of these issues contribute to the outcome the most. According to Brook, Kruskal, Eisenberg, and Larson (2015), the Pareto chart is used to identify the 20% of all factors that affect the 80% of the adverse results. Similarly, they show how the other 80% of all problems create 20% of errors. Brook et al. (2015) suggest focusing on the most vital few, thus targeting a small number of influential factors to resolve the majority of errors.
In this case, the scenario shows that defective scanners are at the root of the problem. Therefore, the Pareto chart indicates that the hospital should look into replacing the current scanners to eliminate around 37% of all mistakes. This method allows the risk manager to see which factors contribute to the problem the most – the focus on these issues may help reduce the number of errors quickly. The approach of relying on the Pareto chart can significantly reduce the error rate in a short period. While other graphs portray all issues as equally impactful, the Pareto chart creates a list of problems with urgent and non-urgent need for a solution.
The contributing factors also include look-alike medication labels, the need for manual entry of numbers, pharmacy technicians’ stress, the lack of communication with the pharmacy, and others. The described medical errors require a multifaceted solution for both the hospital and the pharmacy. The hospital should replace scanners and create means for relieving nurses’ stress (Schiff et al., 2015). The pharmacy should provide its technicians with stress-coping methods as well as develop a more reliable system of communication.
References
Brook, O. R., Kruskal, J. B., Eisenberg, R. L., & Larson, D. B. (2015). Root cause analysis: Learning from adverse safety events. Radiographics, 35(6), 1655-1667.
Schiff, G. D., Amato, M. G., Eguale, T., Boehne, J. J., Wright, A., Koppel, R.,… Seger, A. C. (2015). Computerised physician order entry-related medication errors: Analysis of reported errors and vulnerability testing of current systems. BMJ Quality & Safety, 24(4), 264-271.
Spath, P. (2013). Introduction to healthcare quality management (2nd ed.). Chicago, IL: Health Administration Press.
Yoder-Wise, P. S. (2015). Leading and managing in nursing (6th ed.). St. Louis, MO: Mosby.
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